2. Trauma MCQs

DISCUSSION: The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less chance of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting. REFERENCES: Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190. Jupiter JB: Complex non-union of the humeral diaphysis: Treatment with a medial approach, an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am 1990;72:701-707.

DISCUSSION: A supination-adduction ankle fracture leads to a vertical fracture of the medial malleolus. Traditional fixation of the medial malleolus with oblique screws from the tip of the malleolus directed proximally will ineffectively protect against shear forces at the fracture site; these also are directed quite obliquely to the vertical fracture line, and therefore have poor biomechanical resistance to failure. An antiglide plate is used medially to prevent displacement of the fracture segment due to shear forces. According to the referenced article by Toolan et al, placement of two horizontal (perpendicular to the fracture line) lag screws from medial to lateral are biomechanically the most important aspect of the construct whether a plate is used or not.

DISCUSSION: In adults, a direct blow on the acromion usually results in an acromioclavicular dislocation. In children, however, the usual injury from this mechanism is a physeal fracture of the lateral clavicle. The clavicular shaft fragment, analogous to the metaphyseal portion of a physeal fracture, herniates through the periosteum, leaving the distal periosteal sleeve in contact with the lateral (distal) physeal fragment. The treatment of choice is immobilization until the patient is pain-free. REFERENCES: Falstie-Jensen S, Mikkelsen P: Pseudodislocation of the acromioclavicular joint. J Bone Joint Surg Br 1982;64:368-369. Havranek P: Injuries of the distal clavicular physis in children. J Pediatr Orthop 1989;9:213-215.

Medial plateau fracture dislocations are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the anteroposterior radiograph include an intact lateral column (lateral articular surface still in continuity with tibial shaft), centrolateral articular impaction, shortening, and condylar widening. The medial femoral condyle stays with the fractured medial tibial plateau segment. Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions.

The radiographs and MRI scans both show an avulsion of the anterior cruciate ligament, which has been described by Meyers and McKeever in three different fracture patterns. Type I fractures are nondisplaced or have minimal displacement of the anterior margin. Type II fractures have superior displacement of their anterior aspect with an intact posterior hinge. Type III fractures are completely displaced. Although the injury is visible on the radiographs, it is more subtle in adults than children. Thus, MRI is helpful in clarifying this injury in adults. Open or arthroscopic reduction and internal fixation is recommended for type II and type III fractures that do not respond to closed reduction.

The patient has abundant callus formation but the fracture line is still visible and unchanged on two sets of radiographs. The patient has persistent pain. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing.

Osteonecrosis of the tibial plateau occurs infrequently. The symptoms are similar to those of idiopathic osteonecrosis of the medial femoral condyle and include pain and tenderness of the medial aspect of the knee and a slight synovitis. Osteonecrosis of the tibial plateau is easily misdiagnosed as degenerative meniscus or osteoarthritis of the compartment of the knee.

DISCUSSION: Implant-related fractures following hip fracture surgery were reported by Robinson and associates and showed that the risk of an ipsilateral femoral fracture is significantly increased with the use of short cephalomedullary nails as compared to a compression hip screw. The use of short cephalomedullary nails has not been shown to increase the risk of deep venous thrombosis or nonunion. Cephalomedullary nails overall have decreased surgical blood loss when compared to use of sliding-compression hip-screw devices.

A widened medial clear space indicates instability caused by an associated tear of the deltoid ligament; therefore, nonsurgical management is not warranted. Weber type B distal fibular fractures without a deltoid tear have a medial clear space of < 4 mm, even under stress, and may be successfully treated nonsurgically. The presence of medial hindfoot ecchymosis and medial ankle tenderness is not fully indicative of medial soft-tissue instability. Stress testing is necessary to demonstrate the presence or absence of instability.

DISCUSSION: The referenced study by Loo et al. studied the interaction between airbags/seatbelts and mechanism of the crash (i.e., front vs. side impact) and the injury patterns in these patients. They found that in frontal crashes, airbags reduced Glasgow Coma Scale severity in brain injury, facial fracture, shock, thoracoabdominal injuries, and the need for extrication. Frontal airbags also had a protective effect on lower extremity fractures, but had no significant protective effect on pelvic fractures.

Player A sustained an avulsion fracture of the anterolateral ligament (ALL). Its tibial attachment is midway bewteen Gerdy's tubercle and the fibular head. Player B sustained an avulsion fracture of the arcuate complex.A Segond fracture is commonly associated with ACL tear (75%). It is caused by internal rotation and varus load (unlike the more common cause of ACL tear, which is valgus stress). The arcuate sign is an avulsion fracture of the proximal fibula at the site of insertion of the arcuate ligament complex, and is usually associated with cruciate ligament injury (~90% of cases). The fracture fragment is attached to the LCL or biceps femoris tendon.Dodds et al. reviewed the anatomy of the ALL in 4 cadaveric knees. They found that the ligament was isometric from 0 to 60° of flexion and slackened with the knee flexed to 90°. It passed superficial to the LCL and knee capsule. Mean length was 59 mm, mean width was 6 mm. The femoral attachment was slightly posterior to both the lateral epicondyle and the femoral attachment of the LCL. The tibial attachment just distal to the anterolateral rim of the plateau, mid-way between the head of the fibula and Gerdy’s tubercle. An arcuate complex avulsion fracture is an avulsion of the fibular styloid attachment of the arcuate complex.Claes et al. (2014) compared the distance between the tibial ALL footprint to the center of Gerdy's tubercle (GT, in cadavers) vs the distance between GY and a Segond fracture (on CT). They found the former to be 22mm, and the latter to be

DISCUSSION: The debate between reamed versus unreamed intramedullary nailing of the tibia continues. Although unreamed nailing was proposed for open fractures to minimize infection, its simplicity made it appealing for closed fractures. However, most studies to date show that the only advantage of unreamed nailing is less surgical time. All studies show higher nonunion rates with increased hardware failure and increased time to union for unreamed nailing. Even in open fractures graded up to Gustilo Grade IIIA, the reamed tibial nail performs better. REFERENCES: Larsen LB, Madsen JE, Hoiness PR, et al: Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years’ follow-up. J Orthop Trauma 2004;18:144-149. Blachut PA, O’Brien PJ, Meek RN, et al: Interlocking intramedullary nailing with or without reaming for the treatment of closed fractures of the tibial shaft: A prospective randomized study. J Bone Joint Surg Am 1997;79:640-646.

The standard postoperative weightbearing for locked medullary nailing for femoral shaft fractures and humeral shaft fractures is weight bearing as tolerated (WBAT). Simple ORIF ankle fractures may be managed with early protected weight bearing. ORIF right middle third radius and ulna fracture should be managed with a period of non-weight bearing due to risk of secondary displacement of the fracture.Tingstad et al. examined the effect of immediate weightbearing on plated fractures of the humeral shaft. They reported that immediate weightbearing on humeral shaft fractures, treated with plating and full weightbearing, did not have any negative effect on the union or malunion rates.Brumback et al. evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. Using biomechanical and clinical data, they showed that all fractures united with no loss of fixation or hardware failure.Starkweather et al. retrospectively assessed the complications and loss of reduction in patients who bore weight in a short leg cast within 15 days after surgical repair of acute unilateral closed ankle fractures. Of the 81 ankle fracture radiographs, 80 (98.8%) showed no displacement in fracture reduction on the final follow-up examination. These results suggest early protected weightbearing may be safe.Incorrect Answers:

Although the radiographic evaluation is incomplete, the single lateral view shows a comminuted fracture of the distal femur with suspicion of intra-articular injury and an ipsilateral proximal tibia fracture. This is an open fracture that requires antibiotics, débridement, and skeletal stabilization. The fractures are complicated and the patient is polytraumatized; therefore, rapid but complete surgical débridement and simple stabilization of the knee with a spanning external fixator would be the most appropriate management. Definitive surgical stabilization will likely be complicated and is less desirable during the early post-injury period.

(3787) Q2-7569:Which of the following stress fractures most often requires internal fixation:

The MRI scan findings and patient history demonstrate a compression-sided femoral neck stress fracture. The stress fracture on the coronal MRI scan involves about one third of the width of the femoral neck. Surgical treatment would be recommended for tension-sided fractures of the femoral neck. The most appropriate initial treatment is protected weight bearing, with close examination and imaging follow-up. Skeletal traction is not currently used for nondisplaced femoral neck stress fractures, and there is no indication for open reduction and internal fixation. There is no documented role for pulsed ultrasound or calcium supplements in the acute treatment of stress fractures.

The patient has a nondisplaced stress fracture of the tarsal navicular. Weight bearing is associated with a high rate of nonunion; therefore, management should consist of immobilization and no weight bearing for 8 weeks. Delayed union or nonunion is treated by excision of sclerotic fracture margins and bone grafting, with or without internal fixation.

This patient has likely lost 30-40% of his blood volume and is likely in stage III hemorrhagic shock on the basis of his heart rate, blood pressure, and urine output.Initial assessment of a trauma patient should involve evaluation of airway, breathing and circulation. An average adult has approximately 5 L of circulating blood volume. Class III and IV hemorrhagic shock, approximated by loss of greater than 30% of blood volume, typically requires resuscitation with fluids and blood products. Lactate level (normal <2.5) is typically the most sensitive indicator of adequate perfusion.According to ATLS guidelines, the emphasis of the initial assessment is to assume the worst injury and begin treatment before diagnosis. In cases of hemorrhagic shock, treatment involves aggressive resuscitation with crytalloid and/or blood products.Illustration A is a chart showing the physiological changes associated with different levels of hemorrhagic shockIncorrect Answers:1: Blood loss of <15% typically leads to no changes in vital signs2: Blood loss of 15-30% typically leads to heart rate >100 and diminished urine output4, 5: Blood loss of greater than >40% typically leads to heart rate >140, decreased blood pressure and negligible urine output.OrthoCash 2020Which of the following fracture patterns would be most appropriately treated with open reduction and internal fixation with posteromedial and lateral plates via dual incisions?The patient in Figure D has a bicondylar tibial plateau fracture with a posteromedial fracture fragment, which is an indication for lateral and posteromedial plating via dual incisions.Bicondylar tibial plateau fractures are typically treated with open reduction internal fixation. Studies have shown that the posteromedial fragment is common in bicondylar tibial plateau fractures. Standard lateral implants do not gain adequate screw purchase in posteromedial bone. Posteromedial incisions using the interval between the semimembranosus and medial head of the gastrocnemius can be used to gain access to the fragment and provide exposure to place a posteromedial plate.Barei et al. reviewed 57 OTA C-type bicondylar tibial plateau fractures, and found the presence of a posteromedial fragment in 74% of cases. They suggestthe use of alternate methods of fixation for the posteromedial fragment rather than lateral fixed-angle plates alone.Higgins et al. reviewed 111 patients with bicondylar tibial plateaus that underwent CT scan evaluation. They found the incidence of a posteromedial fragment in 59% of the patients and on average accounted for 25% of the articular surface.Barei et al. reviewed 83 patients treated with dual incisions for fixation of bicondylar tibial plateau fractures. They found deep infections in 8.4% of patients. Satisfactory articular reduction was found in 62% of patients, satisfactory coronal alignment in 91% of patients, satisfactory sagittal alignment in 72%, and satisfactory condylar width in 98%.Figure A shows an AP and lateral radiograph of a split/depressed lateral tibial plateau fracture. Figure B shows an AP and lateral radiograph of a proximal third tibial shaft fracture with a proximal fibula fracture. Figure C shows an AP and lateral radiograph of a medial plateau fracture with articular depression. Figure D shows an AP and lateral radiograph of a bicondylar tibial plateau fracture. Figure E shows an AP and lateral radiograph of a tibial tubercle fracture in a tibia with open physes.Incorrect Answers:OrthoCash 2020Figure A shows the radiographs of a 87-year-old patient after a fall from standing. He lives in a nursing home and uses a walker to transfer from bed to chair. His past medical history includes recurrent urinary tract infections, congestive heart failure, angina and diabetes. Which of the following factors is associated with the best postoperative outcome in this patient?Immediate surgical interventionPostoperative epidural analgesiaPostoperative antibioticsPre-operative medical optimizationChoosing total hip arthroplasty instead of hemiarthroplastyCorrent answer: 4Geriatric patient with hip fractures tends to have a number of coexisting medical conditions that impact surgical risk. A successful pre-operative medical evaluation has the greatest impact on surgical outcomes in this patient population.Patients with complex past medical histories are at great risk of complications with surgery. This helped to drive the formation of the ASA classification system as a way to score patients out of 5 based on their anesthetic and surgical risks. Patients with significant systemic disease (ASA III and IV) have shown to demonstrate poorer outcomes as compared to patients with less severe medical comorbidities (ASA I and II).Egol et al. looked at factors that impact the outcomes of hip fractures in geriatric patients. They showed that cardiac and pulmonary complications were most frequent complications post-operatively. It was stated that early mobilization and pre-operative evaluations have the greatest impact on outcomes.Parvizi et al. looked at the thirty-day mortality following hip arthroplasty for acute fracture. They reviewed a database of 7774 consecutive patients that underwent hip arthroplasty for the treatment of an acute fractures. The overall mortality was 2.4%. Risk factors were found to be cemented implants, female patients, elderly patients, and patients with cardiorespiratory comorbidities.Roberts et al reviewed the 2015 AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly. Although pre-operative medial optimization was not mentioned in this review, there is strong evidence to support an interdisciplinary care program for patients with hip fractures.Figure A shows a displaced left femoral neck fracture. Incorrect Answers:more than 24-48 hours and a higher 1-year mortality rate. However, In patients with with more than 3 medical comorbidities, medical optimization has a greater impact on post-operative outcomes than time to surgery.OrthoCash 2020A 36-year-old male sustains severe injuries as a result of a motor vehicle collision. After 5 days, the patient is stabilized and transferred to your facility for continued management. After obtaining appropriate imaging, including the images shown in Figures A, B and C the patient should be given which of the following mobility restrictions?Touch-down weight bearing on the left lower extremity, non-weightbearing on the right lower extremityWeight bearing as tolerated on the left lower extremity, non-weightbearing on the right lower extremityNon-weight bearing on the left lower extremity, non-weightbearing on the right lower extremityTouch-down weight bearing on the left lower extremity, weight bearing as tolerated on the right lower extremityWeight bearing as tolerated on the left lower extremity, weight bearing as tolerated on the right lower extremityFigures B and C shows a stable, impacted lateral compression (LC) type I injury, which can be treated with immediate mobilization without restrictions. The right lower extremity has a pilon fracture, which should be treated with non-weight bearing.LC-I injuries are stable patterns, as they involve an impaction injury to the anterior sacrum, which has some inherent stability. In addition, the posterior sacro-iliac (SI) soft tissue structures remain intact, which provides critical stability during immediate mobilization.The reference by Tile is a review article on the principles of management of these injuries, and he reviews how the Tile classification system is important to help determine surgical need and where the stabilization is required. For the stable LC-1 type injury, no fixation is required.Incorrect Answers:OrthoCash 2020A 24-year-old male sustains the fracture dislocation shown in Figure A. How is this fracture pattern best classified?Moore IMoore IISchatzker IIISchatzker VOTA type 41B3Corrent answer: 2Figure A shows a Moore Type II fracture. Moore type II fractures consist of fractures involving the entire tibial condyle, where the fracture line begins in the opposite compartment and extends across the tibial eminence.A number of classification systems are used to describe tibial plateau fractures. The main classification systems that are widely used include Schatzker, AO/OTA, Hohl and Moore. The Moore classification describes high energy fracture-subluxation injuries of the knee. This is thought to have clinical implications as the type of fracture pattern can indicate an associated soft-tissue injury.Moore retrospectively reviewed over a 1000 proximal tibia fractures to devise a classification systems based on the characteristic of five types of tibia plateau fracture patterns. He believed this system helped to better understand knee instability and concomitant soft-tissue injury. For example, Moore Type III fractures (rim avulsion) are associated with a high rate of neurovascular injury.Figure A shows a fracture involving the entire tibial condyle. Illustration A shows a schematic diagram of the Moore classification (I - V). Illustration B shows a table that describes the Moore classification (I - V).Incorrect Answers:OrthoCash 2020A 19-year-old male football player plants and twists his right lower extremity sustaining a spiral fracture of his distal third tibial shaft. Of the following images, which is most commonly associated with distal third spiral tibial shaft fractures.The patient has a spiral distal tibial shaft fracture. Spiral distal tibial shaft fractures are commonly associated with intraarticular fracture extension, usually in the form of a posterior malleolus fracture.Spiral distal third tibial shaft fractures need to be evaluated for intraarticular extension prior to operative management. As this can be missed on x-rays, a CT scan of the ankle is recommended to identify this associated injury. This is important when intramedullary fixation is used for definitive management, as nail insertion can displace a previously non displaced intraarticular fracture.Anteroposterior screw fixation prior to nailing may be useful in these cases.Boraiah et al. found that in 62 patients with spiral distal tibial fractures, 39% (24 patients) had a posterior malleolus fracture. They recommended CT evaluation of the ankle to prevent missed intraarticular fractures.Hou et al. found a posterior malleolus fracture in 9.7% (28 out of 288 cases) of patients with tibial shaft fractures. They recommended CT or MRI evaluation of the ankle prior to surgery.Figure A shows an axial CT scan of a right ankle with a posterior malleolusfracture. Figure B shows an AP radiograph of a right ankle with a vertical medial malleolus fracture. Figure C shows a coronal CT scan of a right ankle with a Tillaux fracture. Figure D shows a sagittal CT scan of a right ankle with a comminuted talus fracture. Figure E shows a lateral radiograph of a right knee showing a knee dislocation. Illustration A shows an AP radiograph of a left distal third spiral/oblique tibial shaft fracture. Illustration B shows a lateral radiograph of a left distal third spiral/oblique tibial shaft fracture. Illustration C shows a sagittal CT of a distal third spiral/oblique tibial shaft fracture with a posterior malleolus fracture.Incorrect Answers:OrthoCash 2020A 67-year-old female patient presents with increasing right hip/thigh pain over the past three months, which is now recalcitrant to anti-inflammatories. There is no history of trauma or constitutional symptoms. Her past medical history consists of hypertension, coronary artery disease, osteoporosis and gastric reflux. Physical examination reveals mild pain at the extremes of range of motion of the hip and a painful right sided limp. A radiograph of the right hip is seen in FigureWhat would be the most appropriate treatment for this patient at this time?Observation onlyReferral to physiotherapyMRI spine and hipTotal hip arthroplastyIntramedullary femoral nailCorrent answer: 5This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who hadbeen receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.Incorrect AnswersOrthoCash 2020A right-hand dominant female sustains a right proximal humerus fracture. The patient is provided a sling, and is recommended pendulum exercises with elbow range of motion to begin in 1 to 2weeks. Which of the following would be an indication for surgical management?Age greater than 70 years.Fracture pattern in Figure ASignificant medical comorbidities.Fracture pattern in Figure BFracture pattern in Figure CThe patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity is displaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.Incorrect Answers:OrthoCash 2020A 37-year-old male arrives to the trauma slot following a high-speed motorcycle crash. His Glasgow Coma score is 14 and his only orthopaedic injury is exhibited in Figure A. His current vital signs are a BP of 90/60, HR 120, and a lactate of 2.5 mMol/L. Other findings include a grade 1 splenic laceration and bilateral pulmonary contusions seen on chest radiograph. Which of the following has been suggested as an indication to perform damage control orthopedic care?HR >110Bilateral pulmonary contusions seen on chest radiographSBP = 90mmHgUnilateral femur fractureLactate = 2.5 mMol/LPulmonary contusion severe enough to be diagnosed on chest radiograph alone is an indicator that the patient may benefit from damage control orthopaedics (DCO).Despite the patient's overall stable nature, suffering pulmonary injury severe enough to be seen on x-ray alone suggests that temporary stabilization with staged definitive fixation may avoid potential morbidity.Pape et al. review the evolution and balance of early total care (ETC) and DCO. Summarizing the literature, the authors report several standalone indicators that would justify DCO regardless of stable status. This includes: Injury Severity Score of greater than 40, Injury Severity Score of greater than 20 with chest trauma, multiple injuries with severe pelvic/abdominal trauma/ hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs alone, hypothermia of less than 35 degrees C), and a head injury with an Abbreviated Injury Score of 3 or greater.Figure A exhibits a right femoral shaft fracture. Illustration A exhibits a summarized table stating the criterion used to determine the condition of a polytrauma patient. (Table from Pape et al, PMID: 19726738)Incorrect answers:implement DCO.OrthoCash 2020A 24-year-old patient presents after a fall from the balcony of a third story building in which he landed on his feet. He reports lumbar back pain and numbness in his perineum region. Radiographs of his hips and pelvis are seen in Figure A, while CT images are shown in Figures B and C. How is this fracture pattern best classified?Young-Burgess APC Type IIYoung-Burgess LC Type I"U" Type Spinopelvic DissociationDenis Zone-IDenis Zone-IIThis patient has a Denis zone-III "U" Type Spinopelvic Dissociation of the sacrum.The Denis classification system for sacral fractures is based on anatomical fracture zones. Zone-III fractures involve the spinal canal and have a high rate of associated neurologic injury. It is important to recognize bilateral sacralfractures with a transverse component, as this often causes spinopelvic discontinuity and possible cauda equina. The lack of mechanical continuity between the spine and pelvis will most likely require reduction and fixation for initial stability. There may also be a need for sacral decompression with fixation mechanisms given the onset of neurologic symptoms.Mehta et al. reviewed sacral fractures. They report that patients with a transverse sacral fracture involving more proximal sacral segments (S1, S2, or S3) tend to have a higher prevalence of bladder dysfunction than do those involving distal sacral segments (S4 or S5).Schildhauer et al. report the best way to visualize Denis zone-III "U" type fractures is to obtain a lateral view of the sacrum or sagittal reformatted images with a CT scan. Standard pelvic radiographs often miss this injury.Figure A shows an AP pelvis with suggestion of sacral irregularities. No fracture pattern can be indentified. Figures B and C show CT scan images showing a "U" Type fracture pattern with angulation and translational displacement of the cephalad and caudad parts of the sacrum. Illustration A shows examples of complex sacral Denis zone-III fractures.Incorrect Answers:OrthoCash 2020A 55-year-old male presents with the radiographs seen in Figures A and B after falling off his bike. Physical examination reveals an isolated, closed elbow injury. His limb is neurovascularly intact. Which complication would be most likely with surgical fixation of this injury?Ulnar neuropathyPosterior interosseous nerve injuryEarly loss of fixationElbow flexion contractureAvascular necrosisThis patient is presenting with a comminuted capitellar and trochlear fracture. If treated with open reduction internal fixation, the most likely post-operative complication would be elbow stiffness or contracture.An axial compression force transmitted by the radial head to the capitellum with the elbow in a semiflexed position can result in a shear fracture of the anterior portion of the capitellum. AP, lateral, and radiocapitellar radiographs are recommended to identify these injuries. The lateral X-ray may reveal the “double arc” sign, which represents extension of the capitellum fracture into the trochlea. Extension of the fracture into the trochlea has important implications into the surgical approach to these injuries.Ruchelsman et al. retrospectively reviewed the outcomes of sixteen patients with capitellar fractures treated with open reduction internal fixation. They found the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV capitellar fractures. All fractures healed, and no elbows had instability or weakness with fixation.Ring et al. retrospectively reviewed the outcomes of twenty one distal humerus articular fractures that were reduced and stabilized with implants buried beneath the articular surface. Ten patients required a second operation: (6) release of an elbow contracture; (2) treatment of ulnar neuropathy; (1) removal of hardware; (1) early loss of fixation.Figures A and B show AP and lateral radiographs of the elbow with a comminuted fracture of the capitellum and trochlea. Note the “double arc” sign on the lateral view. Illustrations A and B show open reduction internal fixation of the fracture. Note fixation with multiple interfragmentary screws.Incorrect Answers:OrthoCash 2020Figure A shows a radiograph of a 30-year-old male who underwent fixation of a left leg injury just over two years ago. He presents with persistent pain and drainage from the distal wound despite 4 months of oral antibiotics. He has no systemic symptoms. He has a past medical history of Grave's disease and Irritable Bowel Syndrome. What would be the best management at this stage?Chronic suppressive, culture-directed, antibiotic therapyAbove knee amputationEndocrine consultation, irrigation and debridement, removal of hardware and negative-pressure wound therapyIrrigation and debridement, removal of hardware, over-reaming medullary canal, external fixation and culture-directed antibioticsIrrigation and debridement, retention of hardware, acute bone grafting and culture-directed antibioticsThis is a case of fracture nonunion in the setting of chronic osteomyelitis and infected hardware. The best treatment option available would be irrigation and debridement, removal of hardware, ring external fixator and culture directed antibiotics.The management of infected nonunion in the setting of chronic osteomyelitis is technically demanding. The aims of treatment are to eradicate the infection and obtain bone union. Non-surgical options are largely unsuccessful in patients with draining chronic osteomyeltis in the setting of infected hardware and nonunion. Surgical options involve incision and debridement of necrotic tissue followed by reconstruction of bone and possible soft tissue (to providehealthy viable coverage). The most common techniques are ringed fixator/circular frames, staged intramedullary device with or without external fixator, free tissue transfer, or radical debridement, bone grafting, and fixation.Motsitsi et al. reviewed the management of infected nonunion of long bones. They suggest that the Ilizarov technique is regarded as a standard treatment in infected nonunion of the tibia. When there is bone defect after debridement, the bone can be shortened or treated with bone transport.Egol et al look at a series of patients with chronic osteomyelitis. Limb salvage should be attempted in all patients. The presence of a chronic draining sinus requires surgical debridement and culture directed antibiotics. Infected hardware should be removed. A two-stage strategy is the best and well-proven treatment option.Figure A shows a intramedullary nail in the left tibia. There is a moderate amount of bone loss at the fracture site with mixed sclerotic bone suggestive of osteomyelitis.Incorrect Answers:OrthoCash 2020A 32-year-old male sustained the injury seen in Figure A after a motor vehicle accident. Which of the following factors is most predictive of mortality with this type of injury?Fracture classificationNumber of blood transfusions in the first 24 hoursGenderTime to operative fixationUse of pelvic bindersCorrent answer: 2The best predictors of mortality with pelvic ring fractures include older age and hemodynamic shock at presentation. The amount of blood transfused indicates the severity of hemodynamic instability.Pelvic ring fractures are typically high energy, blunt injuries. The leading cause of mortality with these injuries is hemorrhage and hemodynamic instability.The most common source of hemorrhage include venous injury (80%), which is usually caused by a shearing injury of posterior thin walled venous plexus and bleeding cancellous bone. Other sources of hemorrhage include arterial injury (10-20%) from the superior gluteal artery (posterior ring injury, anterior posterior compression [APC] pattern), internal pudendal artery (anterior ring injury, lateral compression [LC] pattern) and obturator artery.Smith et al. found fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased Injury Severity Scores (ISS) scores. Deaths were most commonly from exsanguination (<24 hours) or multiorgan failure (>24 hours).Starr et al. demonstrated that age and shock on presentation were most predictive of mortality after pelvic ring injury.Figure A shows a APC III pelvic fracture. Illustration A shows a table describing the Young-Burgress classification of pelvic ring fractures.Incorrect Answers:OrthoCash 2020Figure A shows intraoperative radiographs of a 45-year-old patient with a left elbow injury. What would be the next most appropriate step in this patients care?Early range of motionHinged elbow brace for 4 weeksRepair lateral collateral ligamentRemove and upsize implantRemove and downsize implantCorrent answer: 5The intraoperative images are consistent with overstuffing of the ulnohumeral joint during a radial head replacement. The most appropriate next step would be removing and downsizing the implant.Overstuffing the radiohumeral joint by >2.5 mm can significantly alter elbow kinematics. It has also shown to lead to pain and early joint disease. The most sensitive method to assess for overstuffing of the joint is by direct visualisation intra-operatively. This can be performed by visualising the lateral aspect of the ulnohumeral joint when the radial head is resected and comparing this to when the trial radial head is reduced in place. In comparison, radiographic asymmetry of the medial ulnohumeral joint has been shown to be less sensitive. Radiographic findings of incongruity of ulnohumeral joint only occurs when significant overlengthening of the radius occurs.Frank et al. examined the effect of radial head thickness in seven cadaver specimens. They found that incongruity of the medial ulnohumeral joint would only become apparent radiographically after overlengthening of the radius by>or=6 mm.Doornberg et al. examined seventeen computed tomography scans of the elbow to investigate the height of the radial head relative to the lateral edge and central ridge of the coronoid process. They found that the radial head was on average only 0.9 mm more proximal than the lateral edge of the coronoid process.Figure A shows intraoperative radiographs of a patient that has undergone a radial head arthroplasty. There is significant widening of the medial ulnohumeral joint on an AP radiograph as well as widening of the ulnohumeral joint on the lateral radiograph,Incorrect Answers:OrthoCash 2020Aside from improving the intramedullary nail starting point in Figure A, the use of blocking screws could have been used at the time of fixation to prevent this post-operative deformity. What would have been the correct orientation of these screw(s) in the proximal fragment?Medial onlyLateral onlyAnterior and medialPosterior and medialPosterior and lateralCorrent answer: 5The clinical presentation is consistent with a malunion of a proximal one-third tibia fracture with a valgus and procurvatum deformity. The correct orientation of Poller blocking screws to help prevent this malalignment would be in the posterior and lateral aspects of the metaphyseal fragment.Insertion of the blocking screw lateral to the nail prevents valgus deformity, and insertion of the blocking screw posterior to the nail prevents apex anterior deformity. A more lateral starting point for nail insertion can also help toprevent valgus deformity. The semiextended position of the knee for nail insertion also helps to eliminate the tendency for the fracture to flex, due to the avoidance of excessive knee flexion during the reduction.Stedtfeld et al. describes the mechanical model for blocking screws. They state that two or more blocking screws can be placed in each plane (AP and lateral) alongside the nail to create a narrow canal for the nail. This allows for multiple points of fixation and realignment of the bone as the nail is passed.Lindvall et al looked at a series of 56 extra-articular proximal tibial fractures treated with intramedullary nailing or percutaneous locked plating. Neither nailing or plating these fractures showed a distinct advantage in the overall outcomes. Apex anterior malreduction however was the most prevalent form of malreduction in both groups.Lang et al. looked at a series of proximal third tibia fracture treated with intramedullary nailing. They reported that posterior tibial comminution will also contribute to apex anterior angulation. They states this occurs when the fracture hinges on the intact cortex anteriorly during nail insertion.Figure A shows a proximal one third tibia fracture treated with an intramedullary nail. There is malreduction of the fracture with valgus and procurvatum deformity.Incorrect Answers:OrthoCash 2020When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern?A fracture of the radial head requiring ORIFA highly comminuted radial head fracture requiring radial head arthroplasty or resectionAn MCL injury requiring repairA type I avulsion fracture of the coronoidAn anteromedial coronoid fractureA varus and posteromedial rotation mechanism of injury typically results in a fracture of the anteromedial facet of the coronoid which frequently requires reduction and fixation to restore stability.A varus and posteromedial mechanism of injury about the elbow presents with an injury pattern distinctly different from other injury patterns. A key part of treating this injury pattern is recognizing a fracture of the anteromedial facet of the coronoid, which often requires reduction and fixation to restore stability about the elbow. It is important to recognize this during preoperative planning since this injury typically requires a medial approach.Steinman presents a review article describing coronoid fracture patterns and their mechanisms of injury.Doornberg and Ring present a level 4 review showing that coronoid fracture patterns and their required treatments are predictable based on mechanism of injury. Varus and posteromedial mechanisms were found to reliably create a fracture of the anteromedial facet of the coronoid, and were associated with sparing of the MCL and radial head.Doornberg and Ring also presented a Level 3 review of anteromedial facet cornoid fractures. They found that they could not be adequately visualized and treated from a lateral approach, and that they typically required reduction and fixation to restore adequate stability to the elbow. This stresses the importance of recognizing this injury pattern during preoperative planning.Illustrations A and B are AP and lateral radiographs of an elbow following a varus/posteromedial injury with an anteromedial coronoid facet fracture.Illustration C is a diagram demonstrating fracture lines that create an anteromedial facet fracture fragment. This fracture can be subclassified into three subtypes [anteromedial rim (a), rim plus tip (b), and rim and tip plus the sublime tubercle (c)]Incorrect answers:OrthoCash 2020A 26-year-old female presented to the emergency department with the injury seen in Figure A after an awkward fall while intoxicated. She undergoes closed reduction and repeat radiographs are seen in Figure B. After a normal physical examination, including ranging the hip from 0-90 degrees, which of the following options would be the next most appropriate step in management?Femoral skeletal tractionCT scanHip spica cast applicationObservation onlySerial neurovascular examinationsCorrent answer: 2This patient has presented with a posterior left hip dislocation. The next most appropriate step would be performing a post-reduction CT scan to assess for joint reduction and congruity, associated fractures, or loose bodies.Hip dislocations occur most commonly in young patients with high energy trauma. They are usually classified as simple or complex, with complex dislocations being those with associated fractures of the acetabulum or proximal femur. Urgent close reduction should occur within 6 hours from the time of injury. Post reduction CT scans must be performed for all traumatic hip dislocations to look for fractures or impacted areas of the femoral head or acetabulum, as well as incongruent reductions and free intra-articular joint fragments.Calkins et al. looked at measurements of the posterior acetabulum on CT scans (the Acetabular Fracture Index) after hip dislocations to evaluate for hip stability. Hips were found to be unstable if less than 34% of the remaining posterior acetabulum was present after dislocation. Hips with greater than 55% were stable. In between 34 and 55% were indeterminate.Moed et al. found that posterior wall fractures involving less than 20% of the posterior wall were considered stable. Fractures involving more than 40%-50% were unstable, leaving a wide range of posterior wall fractures classified as indeterminate.Figure A shows a left posterior hip dislocation. Figure B shows a reduced left hip with no obvious fracture. Illustration A shows an axial CT scan image of the left hip. There is no acetabular fracture identified.Incorrect Answers:OrthoCash 2020A 40-year-old male sustained the injury seen in Figure A, and subsequently underwent the procedure shown in Figure B. One hour post-operatively he starts to complain of pain in the operative leg, and the pain is unchanged with active or passive stretch. The external dressing is released with little resolution of symptoms. His blood pressure is 115/78 mm Hg with compartment pressures in the leg measuring 31 to 35 mm Hg. His ABI index is 1.1 in the leg. What would be the next step in management?MRI angiography of legFour-compartment fasciotomyFollow-up examination the following dayContinued monitoring and serial examinationsEMG studyThe patient is at risk for developing compartment syndrome of the leg. The next most appropriate step would be to support his systemic blood pressure and monitor compartment pressures.A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam. An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy. However, the treatment of early compartment syndrome should be to initially improve the limbs perfusion pressure gradient. This can be done by treating underlying factors such as hypotension, coagulopathy, or vascular compromise due to either a true vascular injury or artificially by external compression. Frequent reassessment is then critical to effectively manage these patients. If clinicaldiagnosis persists despite these efforts, urgent fasciotomy would be considered.McQueen looked at 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of 30 mmHg is a more reliable indicator of compartment syndrome.White et al. looked at 101 patients with tibial fractures with satisfactory Delta P measurements. THey found that patients with elevated intramuscular pressures >30 mm Hg after tibial fracture do not have a greater incidence of complications than those with low pressures, so long that Delta P <30 mm Hg.Figure A shows a Shatzker V tibial plateau fracture. Figure B shows fixation of fracture seen in Figure A.Incorrect Answers:OrthoCash 2020A 10-year-old girl suffers a displaced tibia fracture. Initial numbness over the dorsum of the the foot resolved following an anatomic closed reduction and placement in a long leg cast performed in the emergency room. The cast was placed with the the ankle dorsiflexed just above neutral to prevent equinus contracture and then the cast and padding was adequately bivalved. Overnight, the patient began experiencing recurrent numbness and paresthesias in her exposed toes and a slight increase in her pain at the fracture site. Your next best step would be:Repeat closed reduction under conscious sedationSelective compartment fasciotomiesExternal fixation and compartment monitoringcompartment fasciotomies with fracture fixation done emergentlyModify the cast to reposition the ankle into slight plantarflexionCorrent answer: 5Circumferential casting with the ankle dorsiflexed can cause increased intracompartmental pressures in the leg. However, this patient's cast has been adequately bivalved during initial cast placement. Therefore, the next best step is cast modification to allow the ankle to assume an angle between neutral and 30 degrees of plantar flexion and further reducing the compartment pressure.Tibia fractures are one of many common underlying etiologies for the development of compartment syndrome in the leg. Fracture reduction as well as eliminating circumferential dressings are important early preventative steps to take. Bivalving casts - including splitting the cast padding - is often indicated in fractures of long bones that are treated with initial casting. While casting patients in a plantigrade or dorsiflexed position reduces the risk of equinus contractures and holds the ankle mortise reduced, dorsiflexing the ankle has been shown to increase the intracompartmental pressures throughout the leg compartments.Weiner et al. placed pressure monitors into the anterior and deep posterior compartments in healthy volunteers to measure the effects of casting on compartment pressures. They found that the intramuscular pressures were lowest with the ankle positioned between plantigrade and a resting plantar flexion position (0-37 degrees), and that bivalving the cast reduced the pressures 33-47%.Illustration A shows the needle trajectories for compartment pressure monitoring in the leg. This should be performed within 5 cm of the fracture to get accurate peak pressures.Incorrect Answers:OrthoCash 2020A 35-year-old male horseback rider was bucked into the air and then landed forcefully with his perineum on the saddlehorn of the saddle. At a one year follow-up, the only long term sequela of his injuries is erectile dysfunction. Which radiographic injury seen in Figures A-E is most commonly associated with this complication?This patient has sustained a saddle-horn injury to the pelvis. An anterior posterior compression (APC) injury is the most common pelvic injury associated with this mechanism.Saddle-horn injury to the pelvis occurs when a horseback rider is bucked into the air and then lands forcefully with his or her perineum on the saddlehorn of the saddle. The bony injury to the pelvis usually consists of a diastasis of the pubic symphysis with/without subsequent widening of the sacroiliac joints. Themajority of patients are able to return close to their pre-injury level of employment and activity after these injuries. However, sexual dysfunction is a common complication with this injury. Sexual dysfunction can be due to urethral, vascular, neurologic, and psychogenic injuries.Collinge et al. looked at a series of male patients with injuries to the perineum after coming into contact with the saddle or saddle horn on a horse. Eighteen of the twenty patients were found to have sexual dysfunction at the time of the latest follow-up. A multi-disciplinary approach to these patients is needed when treating pelvic injuries.Cannada et al. surveyed 71 women of childbearing age who had a pelvic fracture. She found that half the patients reported physical genitourinary complaints with 38 percent of women noting new onset pain with intercourse. In terms of psychological impact, they showed that 45 percent of patients answered affirmatively to decreased interest in intercourse and decreased orgasm frequency after the injury.van Nieuwenhoven et al. describe three equestrians who suffered from straddle injuries with symphysis diastasis and rupture of sacroiliac ligaments after falls or kicks from horses. They show that these presumed low-energy injuries can cause extremely severe injuries to the pelvis itself and to the adjacent organs.Figure A shows a Burgess APC Type II pelvic fracture. Figure B shows left ASIS avulsion fracture. Figure C shows a left hip dislocation. No pelvic fracture is identified. Figure D shows a subacute superior/inferior pubic rami fracture.Figure E shows a right femoral neck fracture.Incorrect Answers:OrthoCash 2020A 31-year-old male driver was involved in a high-speed motor vehicle accident. His injuries include a left subdural hematoma (Abbreviated Injury Score [AIS]=4), left segmental femur fracture (AIS=3), ruptured spleen (AIS=4), nasal fracture (AIS=2), fractured left ribs 4 to 7 (AIS=2), and a closed pelvic ring fracture (AIS=3). What is his Injury Severity Score (ISS)?